Alternative Model of Personality Disorders (DSM-5) Predicts Dropout in Inpatient Psychotherapy for Patients With Personality Disorder

What if we wait? Using synthetic waiting lists to estimate treatment effects in routine outcome data

Objective: Due to the lack of randomization, pre-post routine outcome data precludes causal conclusions. We propose the "synthetic waiting list" (SWL) control group to overcome this limitation.

Method: First, a step-by-step introduction illustrates this novel approach. Then, this approach is demonstrated using an empirical example with data from an outpatient cognitive-behavioral therapy (CBT) clinic (N = 139). We trained an ensemble machine learning model ("Super Learner") on a data set of patients waiting for treatment (N = 311) to make counterfactual predictions of symptom change during this hypothetical period.

Results: The between-group treatment effect was estimated to be d = 0.42. Of the patients who received CBT, 43.88% achieved reliable and clinically significant change, while this probability was estimated to be 14.54% in the SWL group. Counterfactual estimates suggest a clear net benefit of psychotherapy for 41% of patients. In 32%, the benefit was unclear, and 27% would have improved similarly without receiving CBT.

Conclusions: The SWL is a viable new approach that provides between-group outcome estimates similar to those reported in the literature comparing psychotherapy with high-intensity control interventions. It holds the potential to mitigate common limitations of routine outcome data analysis.

Levels of Personality Functioning Questionnaire 12-18 (LoPF-Q 12-18): Factor Structure, Validity, and Clinical Cut-Offs

The Levels of Personality Functioning Questionnaire 12-18 (LoPF-Q 12-18) is the only self-report measure informed by the Level of Personality Functioning (Diagnostic and Statistical Manual of Mental Disorders [5th ed.; DSM-5; American Psychiatric Association, 2013]) Alternative Model of Personality Disorders developed for adolescents. The present investigation includes two studies evaluating the English LoPF-Q 12-18. In Study 1, single-factor and bifactor structures (unidimensional severity criterion and four specific factors: identity, self-direction, empathy, intimacy) were evaluated in an ethnically diverse community sample (N = 453; age 10-18; 57% female). Study 2 used a community control (n = 298; age 10-18; 54.4% female) and clinical sample (n = 94; age 11-18; 58.5% female) to examine reliability, validity, and clinical utility. Study 1 results supported the bifactor model, with a robust general factor and little multidimensionality caused by the group factors, suggesting an essentially unidimensional structure. Study 2 revealed good internal consistency and construct validity and provided clinical cut-offs, supporting the use of the LoPF-Q 12-18 total score in research and clinical applications.

Maladaptive Self- and Interpersonal Functioning Increments General Psychiatric Severity in the Association with Adolescent Personality Pathology

Dimensionalized diagnostic systems, especially the entry criterion of maladaptive self and interpersonal functioning, hold particular advantages for the downward extension of personality pathology to young persons, but require conceptual clarification. The current study evaluated the distinctiveness of maladaptive self and interpersonal functioning by examining its incremental value over and above general psychiatric severity in the association with personality pathology. A community sample of N = 419 youth (50.4% female; M_age = 11.91, SD = 1.19) between the ages of 10 and 14 completed measures of maladaptive self- and interpersonal functioning, general psychiatric severity (internalizing-externalizing spectrum), and personality pathology. Results showed that, as expected, maladaptive self- and interpersonal functioning incremented general psychiatric severity in the association with personality pathology in adolescents. Results contribute to the literature base illustrating the value of the entry criterion of the ICD-11 and AMPD diagnostic system.

The impact of personality disorders and personality traits on psychotherapy treatment outcome of eating disorders: A systematic review

A significant proportion of those with eating disorders (EDs) do not respond to first-line treatments. This systematic review was conducted to identify whether personality disorders (PDs)/traits predict or moderate ED treatment outcomes and whether these outcomes were differentially influenced by ED or PD diagnostic subtypes, or treatment approach. A comprehensive systematic literature search was conducted using the PRISMA guidelines. A total of seven randomised controlled trials (RCTs) plus four follow-up studies were reviewed investigating the impact of PD and PD traits on treatment outcomes for EDs. The majority indicated that PD had some impact on treatment outcomes. Outcome measures and time-point measurements varied across studies. Included studies suggested that bulimia nervosa treatment outcomes were not hindered by co-morbidity of borderline PD; however, psychiatric impairment remained high at post-treatment and follow-up. Cluster C PDs were found to negatively impact treatment outcomes for binge ED and attrition rates for anorexia nervosa. Included studies suggested that interventions that addressed aspects of personality pathology showed greater main effects for ED treatment outcomes. There is an urgent need for future RCTs on ED treatments to include routine measures of core personality features to allow their impacts to be more thoroughly examined and for psychotherapies to be tailored accordingly.

Level of Structural Integration and Its Association with Intersession Experiences and Outcomes: A Pilot Study

The level of structural integration (LSI), a psychodynamic/psychoanalytic concept originally developed by the Operationalized Psychodynamic Diagnosis (OPD), provides a promising empirical approach that is recognized beyond the boundaries of psychoanalysis and is highly relevant for therapy and research. The aim of our study was to investigate the intersession experiences of patients in psychotherapy with different levels of structural integration. The sample consisted of 69 inpatients who were undergoing psychotherapeutic treatment. The patients were asked to complete the German version of the Intersession Experience Questionnaire (IEQ), the short version of the OPD Structure Questionnaire (OPD-SQS) and the Brief-Symptom Inventory (BSI). LSI is associated with the situations, contents and negative emotions in the intersession experiences of patients, as well as their symptom distress over the course of therapy. Furthermore, the level of structural integration is a significant predictor of outcomes. Patients with different LSI had different intersession experiences.

The interplay of Criterion A of the Alternative Model for Personality Disorders, mentalization and resilience during the COVID-19 pandemic

Background and aims

The COVID-19 pandemic has been accompanied by a worsening of mental health levels in some, while others manage to adapt or recover relatively quickly. Transdiagnostic factors such as personality functioning are thought to be involved in determining mental health outcomes. The present study focused on two constructs of personality functioning, Criterion A of the Alternative Model for Personality Disorders (AMPD, DSM-5) and mentalization, as predictors of depressive symptoms and life satisfaction during the COVID-19 pandemic. A second focus of the study was to examine whether this relationship was mediated by resilience.

Methods

Linear regression analyses were used to examine the relationship between personality functioning measured by Criterion A (AMPD, DSM-5) and mentalizing abilities as predictors, and depression and life satisfaction as mental health outcomes. To assess the hypothesis that this relationship is mediated by resilience a structural equation modeling approach was conducted. Data from N = 316 individuals from the general population were collected.

Results

Linear regression models revealed highly significant associations between Criterion A/mentalization and both outcome measures. Structural equation models showed a significant partial mediation by resilience of these relationships.

Conclusion

Our results support the hypothesis that mentalizing serves as a protective function by promoting resilience to the impact of stress and threats. Criterion A and mentalization performed similarly as predictors of mental health outcomes, providing empirically overlapping operationalizations of personality functioning. This finding emphasizes the importance of personality functioning in positive and negative mental health outcomes. Furthermore, our results are consistent with a mediating role of resilience.

Differences in personality functioning impairment in mood, anxiety, and personality disorders: a cluster analysis

BACKGROUND

The Alternative DSM-5 Model for Personality Disorders and the latest eleventh version of the International Classification of Diseases implement the level of impairment in self and interpersonal personality functioning (Level of Personality Functioning Scale - LPFS) as a core feature of personality pathology. However, some studies have indicated that personality functioning is also impaired in other mental disorders, but a more thorough exploration is missing. Thus, this study aims to develop profiles of levels of personality functioning in people with personality disorders and some other psychiatric diagnoses as well as without diagnosis.

METHODS

One-hundred-forty-nine people participated in the study. They came from three groups - healthy controls (n = 53), people with personality disorders (n = 58), and people with mood and anxiety disorders (n = 38). The LPFS was assessed by the Semi-structured Interview for Personality Functioning DSM-5 (STiP-5.1). An optimal clustering solution using agglomerative hierarchical cluster analysis was generated to represent profiles of personality functioning.

RESULTS

The two patient groups showed significantly higher levels of personality functioning impairment than healthy controls. People with personality disorders showed higher levels of impairment than the other groups. In addition, the clustering analysis revealed three distinct profiles of personality functioning.

CONCLUSIONS

The impairment of personality functioning seems to be useful in the clinical assessment of other than personality disorders as well. As the resulting clustering profiles suggest, LPFS can be seen as an overall indicator of the severity of mental health difficulties and the presence of mental disorders symptoms. The LPFS provides valuable and detailed information about the individual's mental health and can thus serve as a broad basis for case formulation, treatment and therapy planning, and prognosis.

Vulnerability of personality disorder during the Covid-19 crises - a multicenter survey of treatment experiences among patients referred to treatment

BACKGROUND

The societal shutdown due to the Covid-19 pandemic involved mental health services for personality disorder (PD) and was introduced from 12 March 2020 in Norway. Rapid implementation of treatment modifications was required for patients typically characterized by insecure attachment and vulnerability to separation.

AIM

To investigate immediate reactions to the shutdown of services; alternative treatment received; and differences related to age in a clinical sample of patients with PD.

DESIGN

A survey performed from June to October 2020 (after the first Covid-19 wave) among 1120 patients from 12 units offering comprehensive group-based PD programs.

RESULTS

The response-rate was 12% (N = 133). Negative feelings of anxiety, sadness, and helplessness were noteworthy immediate reactions, but the dominating attitude was accommodation. Younger patients (<26 years) reported more skepticism and less relief. Modified treatment was mainly telephone therapy. Digital therapy was less available, but was more frequent among younger patients. A minority received digital group therapy. Most patients rated the frequency and quality of modified treatments as satisfactory in the given situation, but also worried about own treatment progress, lack of group therapy, and 47% missed seeing the therapist when having telephone consultations.

CONCLUSION

The survey confirms a radical modification from comprehensive group-based PD programs to telephone consultations, low availability of digital consultations and group treatments. Taking a short-term, first wave perspective, the survey indicates a noteworthy capacity among poorly functioning patients for accommodating to a clearly challenging situation, as well as considerable concern about treatment progress.

A New Routine for Analyzing Brief Symptom Inventory Profiles in Chronic Pain Patients to Evaluate Psychological Comorbidity

Question: Comorbidity, i.e., additional psychological distress in patients already suffering from chronic somatic diseases (e.g., orthopedic conditions) is of growing importance. The quality of analyzing and interpreting the often used Brief Symptom Inventory (BSI) used with orthopedic patients should improve by employing a new "case definition" of four groups (instead of two) of differentially psychologically distressed patients instead of two groups as before. Methods: Four groups with the different psychological distress definitions of "no," "mild," "remarkable," and "severe" were to be analyzed from a group of 639 orthopedic patients in inpatient rehabilitation clinics. The BSI is transformed into T values (M=50, SD=10). There is "no" distress if no T [two scales] is ≥60 and "mild" distress if T [two scales] and/or T [GSI] is ≥60 and <63. If T [two scales] and/or T [GSI] is ≥63 and <70, it is "remarkable," and if T [two scales] and/or T [GSI] ≥70, it speaks for "severe" psychological distress. Results: The new tool for analyzing psychological distress based on the T-scores of the BSI resulted in the following four groups: No psychological distress (41.9%): unspecific health-related information stands for a useful intervention. About 13.3% demonstrated low psychological distress: shorter diagnostic interviews and a few more diagnostic examinations led to a low-level outpatient group program to improve health and well-being in a preventive sense; one repeated measurement in 4weeks is advised. Remarkable psychological distress (26%): in-depth exploration using interviews, tests, and questionnaires to choose specific interventions in a single and/or group setting, outpatient or inpatient treatment; repeated measurements and process control. About 18.8% reported severe psychological distress: in-depth exploration led to specific interventions in a single and/or group setting, almost an inpatient setting; immediately crisis intervention and high-frequent process control. Conclusion: The new evaluation strategy of the BSI should improve practice and research; further investigation is necessary.

Vulnerability of personality disorder during COVID-19 crises: a multicenter survey of mental and social distress among patients referred to treatment

BACKGROUND

Relational and emotional problems, dysregulation, self-harming or substance abuse often characterize personality disorders (PD). In Norway, COVID-19 restrictions led to an abrupt shutdown of services from 12 March 2020 also including specialized PD treatments.

AIMS

The objective of this study was to investigate social and mental distress among patients with PDs during the first COVID-19 wave.

DESIGN

A survey was distributed after the first COVID-19 wave (June-October 2020) among 1120 patients from 12 PD treatment units.

RESULTS

The response rate was 12% (N = 133). The survey reflected impairment of occupational activity (53% <50% activity last 6 months), life quality (EQ-5D-VAS: 56, SD 19), and personality functioning (LPFS-BF ≥12: 81%, 35% avoidant PD, 44% borderline PD) and high levels of depression and anxiety (PHQ-9 ≥ 10: 84%, GAD-7 ≥ 10: 68%), 49% with health-related anxiety. Problem increase was reported for anxiety (28%), depression (24%), aggression (23%), substance use (14%), and 70% of parents had more child-care difficulties. Self-destructive behaviors (26%) did not increase. The majority (78%) reported increased or unchanged social isolation and loneliness. Occupational activity declined with negative effects on part-time jobs/rehabilitation. Therapist contact was mainly telephone-based (63% ≥ weekly contact). More severe personality problems, current depressive symptoms, and self-harming before 12 March were associated with more frequent consultations.

CONCLUSION

The survey confirms severe, enhanced levels of mental distress among patients receiving telephone-based consultations as the main alternative to specialized PD treatment during the COVID-19 shutdown. The most vulnerable patients received more frequent consultations and self-destructive actions did not increase.

Three Dimensional Approaches to Personality Disorders: a Review on Personality Functioning, Personality Structure, and Personality Organization

PURPOSE OF REVIEW

The concept of personality functioning (Alternative DSM-5 Model of Personality Disorders) has led to increased interest in dimensional personality disorder diagnosis. While differing markedly from the current categorical classification, it is closely related to the psychodynamic concepts of personality structure and personality organization. In this review, the three dimensional approaches, their underlying models, and common instruments are introduced, and empirical studies on similarities and differences between the concepts and the categorical classification are summarized. Additionally, a case example illustrates the clinical application.

RECENT FINDINGS

Numerous studies demonstrate the broad empirical basis, validated assessment instruments and clinical usefulness of the dimensional concepts. Their advantages compared to the categorical approach, but also the respective differences, have been demonstrated empirically, in line with clinical observations. Evidence supports the three dimensional concepts, which share conceptual overlap, but also entail unique aspects of personality pathology, respectively.

Vulnerable narcissism as beneficial factor for the therapeutic alliance in borderline personality disorder

Evidence suggests that narcissism and borderline personality disorder are associated with each other. This naturalistic study investigated the predictive value of grandiose and vulnerable narcissism on the development of the therapeutic alliance in short-term psychodynamic treatment across 12 weeks. The sample consisted of 99 patients with borderline personality disorder. Narcissism was assessed with the Pathological Narcissism Inventory at treatment onset. The therapeutic alliance was rated with the Scale to Assess Therapeutic Relationships by both patient and therapist at four time points during treatment. Results showed a significant predictive value of vulnerable narcissism on the therapeutic alliance, revealing a more beneficial progression for patients with higher vulnerable narcissism. Grandiose narcissism had no predictive value on the therapeutic alliance. The study strengthens the clinical utility of the concept of vulnerable narcissism towards the evaluation of treatment processes in borderline personality disorder.

How does level of personality functioning inform clinical management and treatment? Implications for ICD-11 classification of personality disorder severity

PURPOSE OF REVIEW

The International Classification of Diseases, 11th Edition (ICD-11) classifies personality disturbance according to levels of severity. This article reviews the literature on levels of personality functioning in relation to clinical management and treatment, and proposes how these findings apply to the ICD-11 classification of personality disorders.

RECENT FINDINGS

Findings were primarily derived from studies using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Level of Personality Functioning Scale (LPFS), Kernberg's Level of Personality Organization, and the general P-factor of personality disorder. Severity of personality dysfunction is related to treatment outcome, risk of dropout, therapeutic alliance, readiness for treatment, risk of harm to self or others, risk of dissociation and psychotic-like breaks, coherence in narrative identity, reflective functioning, and epistemic trust.

SUMMARY

The overall level of personality disorder severity indicates risk of negative outcomes and may be used as decision tool for 'personalized medicine' and required treatment intensity (e.g., strength of alliance and the need for establishing epistemic trust). Beyond the ICD-11 guidelines for determining personality disorder severity, these implications also apply to practitioners using comparable frameworks such as the DSM-5 LPFS and Kernberg's Level of Personality Organization. Future research should focus on the interaction of severity with trait qualifiers in relation to clinical management.

Impulsiveness in borderline personality disorder predicts the long-term outcome of a psychodynamic treatment programme

Despite the preponderance of treatment outcome predictors in patients with borderline personality disorder (BPD), the predictive value of measures of impulsiveness is inconclusive. This naturalistic study consecutively included hospitalized patients with BPD (N = 99) who underwent a standardized and structured 12-week inpatient treatment programme, which integrated cognitive-behavioural and psychodynamic elements. The Brief Symptom Checklist (BSCL) was applied as outcome measure over four time points: pretreatment, posttreatment, first follow-up at 6 to 8 weeks and second follow-up at 1 year after discharge. Impulsiveness was measured using the Barratt Impulsiveness Scale (BIS) at the pretreatment time point. The BSCL significantly decreased between pretreatment and posttreatment, followed by an increase after posttreatment without reaching pretreatment extent. The temporal course of the BSCL significantly varied with pretreatment BIS in that patients with higher impulsiveness revealed a stronger re-increase of symptom severity from posttreatment to end of follow-up than those with lower impulsiveness. The least impulsive patients thereby showed no rebound effect. The robustness of the results was examined by cross-validation. The results indicate that irrespective of the level of impulsiveness, patients with BPD profit from a structured inpatient treatment. However, long-term treatment success was impaired in patients with high level of impulsiveness at pretreatment. Thus, self-ratings of impulsiveness in BPD patients can be utilized for treatment planning. After discontinuation of interventions, relapse prevention should be implemented early in high impulsive patients as symptoms recrudesce in the course after discharge.

DSM-5 Level of Personality Functioning: Refocusing Personality Disorder on What It Means to Be Human

Level of Personality Functioning (LPF) represents the entry criterion (Criterion A) of the Alternative Model for Personality Disorders (AMPD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It is defined as a dimensional general severity criterion common to all personality disorders and conceptually independent of personality types or traits, and it represents maladaptive self (identity and self-direction) and interpersonal (empathy and intimacy) functioning. We review the history, measurement, and significance of LPF. We show that the inclusion of LPF in the AMPD is well justified if it is defined as a general adaptive failure of a subjective intrapsychic system needed to fulfill adult life tasks. If so defined, LPF distinguishes itself from maladaptive traits (Criterion B of the AMPD) and captures the contribution humans make as agentic authors to the interpretation and management of the self. While Criterion B maladaptive traits provide important descriptive nuance to manifestations of personality pathology, maladaptive LPF is conditional to the diagnosis of personality disorder.

A Brief but Comprehensive Review of Research on the Alternative DSM-5 Model for Personality Disorders

PURPOSE OF REVIEW

Both the Alternative DSM-5 Model for Personality Disorders (AMPD) and the chapter on personality disorders (PD) in the recent version of ICD-11 embody a shift from a categorical to a dimensional paradigm for the classification of PD. We describe these new models, summarize available measures, and provide a comprehensive review of research on the AMPD.

RECENT FINDINGS

A total of 237 publications on severity (criterion A) and maladaptive traits (criterion B) of the AMPD indicate (a) acceptable interrater reliability, (b) largely consistent latent structures, (c) substantial convergence with a range of theoretically and clinically relevant external measures, and (d) some evidence for incremental validity when controlling for categorical PD diagnoses. However, measures of criterion A and B are highly correlated, which poses conceptual challenges. The AMPD has stimulated extensive research with promising findings. We highlight open questions and provide recommendations for future research.